Trial Information

International Study for Treatment of Standard Risk Childhood Relapsed ALL 2010 A Randomized Phase III Study Conducted by the Resistant Disease Committee of the International BFM Study Group

ALL is the most frequent malignancy in childhood and has favourable event-free and overall
survival rates. About 15% of patients suffer relapse. At relapse prognosis is much inferior
(about 50% survival) leukemic clones exhibit much more resistance to conventional
chemotherapy. Patients with relapse require treatment intensification and different
therapeutic strategies. At relapse, new targeted agents can provide the chance for better
cure rates and need to be investigated in prospective controlled trials before they may be
even eligible for frontline treatment strategies.

The IntReALL SR 2010 trial is designed to achieve 2 major aims: Establishment of the best
available standard chemotherapy treatment. This is addressed with the randomization of the 2
best developed strategies for treatment of childhood relapsed ALL, the German ALL-REZ BFM
2002 Protocol with the Protocol II IDA arm, and the British ALL-R3 protocol with the
mitoxantrone arm. This randomization allows confirming the feasibility of both protocols in
a large variety of different countries and study groups with different frontline therapy
strategies. As result from this trial a common standard chemotherapy for childhood relapsed
ALL will be developed which can serve as backbone for investigation of the most attractive
targeted new agents.

The 2nd aim is the investigation of the efficacy and tolerability of the humanized CD22
directed monoclonal antibody Epratuzumab, manufactured and provided by the company
Immunomedics, US. The drug will be randomly added to the respective consolidation
chemotherapy, using EFS as primary endpoint. Epratuzumab has been developed in adult
rheumatology indications and in B-cell malignancies. A phase I and early phase II
combination trial in childhood relapse ALL has been conducted and published by the
Children's Oncology Group (COG), and results of an extended phase II trial have been
recently presented at the ASH meeting (12/2011). The drug showed a very favourable safety
profile as single drug and in combination with multidrug chemotherapy. Activity was
moderate, the recent trial showed a significantly better elimination of minimal residual
disease (MRD) in patients achieving a 2nd complete remission. This finding supports the
strategy to use Epratuzumab in combination with consolidation chemotherapy after induction
in patients having reduced the leukemia burden in the bone marrow to at least below 25%,
most of them will be in 2nd complete remission. Epratuzumab will be given weekly at the
established dose. Pharmacokinetics will be investigated in a reduced number of patients. The
further treatment will be conventional intensive chemotherapy and maintenance therapy in
patients with good MRD response after induction, or with allogeneic stem-cell
transplantation (SCT) in those with insufficient MRD response. SCT will be considered as
standard treatment element and will not lead to censoring of the patients of considered as
endpoint. Epratuzumab is not licensed so far and the trial may add to the approval process
in case.

Scientific advice for the trial has been requested at the FDA and the EMA. Both institutions
have responded supportively. Concerns and recommendations of FDA and EMA have been addressed
in the protocol and the corresponding statistical analysis plan.

The IntReALL SR 2010 trial will be financed within the FP7 project IntReALL 2010 supported
by the European Commission. Within the project next to the SR trial a strategy for HR
patients will be addressed, the establishment of harmonized diagnostic procedures, an
international tumour bank and a comprehensive biologic/scientific programme will be set up,
a web-based GCP conform database will be established, a comprehensive statistical strategy
for both trials are established, and drug development in this indication will be promoted
and organized from side of the disease experts in cooperation with the established academic
structures ITCC (Innovative Therapies for Children with Cancer), the ENCCA project (European
Network for Cancer in Children and Adolescents) and SIOPe (International Society for
Pediatric Oncology Europe), the central authorities (EMA, FDA) and Industry. Parent
organisation and former patients are integrated into and accompany the process.

Main aims of the IntReALL FP7 project are to establish a therapeutic platform for children
with relapsed ALL in Europe and beyond and to give them access to the most promising new
agents under academic control and free from commercial interests.

Randomized evidence for efficacy and tolerability of new drugs are demanded by competent
authorities. These trials are conducted beyond the mostly palliative patient group eligible
for phase I/II trials in curative indications. Treatment protocols for with curative
indications need to be conducted in the best interests of the patients, ideally with an
academic sponsor. The design should be driven by medical and scientific evidence and not by
commercial interests as is the case in industry sponsored trials. This concept was
acknowledged by the European Commission selecting the project for funding from many other
powerful applications.